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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374602164
Report Date: 08/11/2022
Date Signed: 08/11/2022 10:56:35 AM


Document Has Been Signed on 08/11/2022 10:56 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108



FACILITY NAME:SANTA MARTHA RESIDENTIAL IIIFACILITY NUMBER:
374602164
ADMINISTRATOR:FLORA M. KELLYFACILITY TYPE:
740
ADDRESS:5706 TULANE STTELEPHONE:
(858) 642-0572
CITY:SAN DIEGOSTATE: CAZIP CODE:
92122
CAPACITY:6CENSUS: 3DATE:
08/11/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:40 AM
MET WITH:Administrator, Martha kelly and Caregiver, Jose CarvajalTIME COMPLETED:
11:10 AM
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Licensing Program Analyst (LPA), Sabel Martinez, conducted an unannounced annual required licensing inspection. The LPA was allowed entry into the facility by Caregiver, Jose Carvajal, and stated the purpose of today’s visit, to verify compliance with statutes, regulations and other written requirements that are most relevant to protecting the health of residents in care and staff, including in the area of infection control practices.

During today's visit, the LPA observed one central entry point for universal entry screening; routine symptom screening initiated at entry for staff, residents and visitors; a sign-in policy enacted for all visitors; signs posted at facility entrance with the facility’s visitor policy and signs throughout the facility to promote hand hygiene, cough/sneeze etiquette and physical distancing; hand sanitizer/hand washing stations readily available; a designated visitation area; emergency agencies’ contact information posted in a location visible to staff and residents; and an adequate supply of PPE. The LPA will provide additional PPE supplies to the facility. The facility is in compliance with and has implemented infection control practices as outlined in its LIC 808.

No deficiencies were observed during today’s visit. An exit interview was conducted with Administrator, Martha Kelly, to whom a copy of this report and Licensee Rights (LIC 9058 01/16) were provided to.
SUPERVISOR'S NAME: Denise PowellTELEPHONE: (610) 767-2317
LICENSING EVALUATOR NAME: Sabel MartinezTELEPHONE: (619) 767-2301
LICENSING EVALUATOR SIGNATURE:
DATE: 08/11/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/11/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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